Provider Demographics
NPI:1376736660
Name:LULLOFF, ELIZABETH A (CRNA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:LULLOFF
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:A
Other - Last Name:CAVIL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:835 S. VANBUREN STREET
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-3400
Mailing Address - Country:US
Mailing Address - Phone:920-433-0111
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:835 SOUTH VANBUREN STREET
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3505
Practice Address - Country:US
Practice Address - Phone:920-433-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-21
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3193-033363L00000X
WI3193-33367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1376736660Medicaid
WI141374-030OtherRN
WI1376736660Medicaid
WI738440089Medicare PIN
WIK400141433Medicare Oscar/Certification
WIP01391304Medicare Oscar/Certification
WI650030042Medicare PIN